- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.55 / $1,630.55 / $1,921.69
| Professional | | $1,630.55 | $1,630.55 | $1,921.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.05 / $2,265.73 / $2,265.73
| Professional | | $1,918.05 | $2,265.73 | $2,265.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,440.31 / $2,741.76 / $3,235.28
| Professional | | $2,440.31 | $2,741.76 | $3,235.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.84 / $2,175.10 / $2,537.61
| Professional | | $1,993.84 | $2,175.10 | $2,537.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.83 / $2,265.73 / $2,920.40
| Professional | | $1,848.83 | $2,265.73 | $2,920.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,800.27 / $2,477.61
| Professional | | $29.27 | $1,800.27 | $2,477.61 |